Setting standards for Culturally and Linguistically Appropriate Care: Models and lessons from the US and abroad

Federal regulations require health care organizations to provide language services for limited English proficiency (LEP) patients. The National Standards on Culturally and Linguistically Appropriate Services (CLAS standards) in Health Care, issued by the Office of Minority Health, include 4 that outline what it means to provide adequate linguistic access services to LEP patients as proscribed in Title VI of the Civil Rights Act. It is not known how US hospitals have incorporated the CLAS standards into practice.
We sampled 239 hospitals using 2 different methods: a directed and a national sample. Both samples were generated as a part of the Hospitals, Language, and Culture Study (HLC), recently conducted by The Joint Commission. We received survey responses from 135/221 (61%). We used standard frequency analyses to describe the study sample and their responses. We conducted bivariate analyses using the χ² or Fishers Exact test, where appropriate, to assess differences between responders and nonresponders and between the directed and national sample subgroups.
Seventy-eight percent of hospitals were able to provide interpreters for their most common language within 15 minutes during business hours, but only 48% could provide interpreters in that time frame for their third most common language. Hospitals were more challenged to inform patients of their right to linguistically accessible services. Less than 50% did so via Patients’ Bill of Rights forms and posters in other languages and in English (48% and 44%), forms or brochures in other languages and in English (40% and 29%), multilingual posters (32%), verbally in other languages (33%), through interpreter services outreach (4%) and media campaigns (2%).  Most hospitals did not meet the standard regarding use of competent interpreters either: 62% reported that family members or friends of patients were used as interpreters, even though 70% of these hospitals also reported having a policy prohibiting this practice. Most hospitals required that staff (79%) and contract (63%) interpreters undergo interpreter training, but ad-hoc interpreters, such as volunteers and bilingual staff usually did not. Finally, hospitals made the following translated documents available in their most commonly requested language: Advance directives (65%), patients’ rights (61%), discharge instructions (58%), informed consent (57%) and hospital signage (51%). Less than a third of hospitals had these written documents available in two or more non-English languages. Very few hospitals could provide all of these forms in their most common language (17%).
Our study documents that many hospitals are not providing language access services as required by federal law, even those that are held up as example institutions. Enforcement of Title VI is difficult and infrequent and the threat of enforcement is not a big enough concern to motivate hospitals. Hospitals will likely be moved into greater compliance due to efforts by The Joint Commission, the National Quality Forum, and the National Committee for Quality Assurance, all of which are using the CLAS standards to develop standards for linguistically accessible care. Our study reinforces the importance of these efforts and helps target interventions to improve the delivery and safety of care to LEP patients.